Children Using Psychotropics Account for 16% of Medicaid Drug Costs

Jul 10, 2014
Children using mental health medications had nearly 3.5 times more overall prescription claims than those not using these medications, and the average cost of a prescription is 57% higher.
  • Medicaid
  • Attention Disorders
  • Depression
  • Mental/Neurological Disorders
  • Seizures
  • Children
  • Teenagers

The prevalence of mental health conditions in Medicaid, including those within the pediatric population, drives large expenditures for state and managed Medicaid plans. To better understand the treatment of mental health conditions in the pediatric Medicaid population, Express Scripts recently conducted an analysis of prescription claims for mental health medications* – specifically, antipsychotics, antidepressants, anti-anxiety medications and mood stabilizers – for children in Medicaid in 2012. 

According to the research, overall cost and medication use is higher for children who take psychotropic medication, and the trend is apart from, but only amplified further by, comorbid use of medications to treat attention deficit hyperactivity disorder. Children using mental health medications had nearly 3.5 times more overall prescription claims – including prescriptions for other conditions – than those not using these medications, and the average cost of a prescription is 57% higher.

Pediatric Mental Health Crisis

A 2014 report from The Agency for Healthcare Research and Quality shows mental health conditions are consistently found to be the largest expenditure for children’s health. Prescription medications are the biggest driver of this expense at 41.4%, with direct medical costs totaling $13.8 billion in 2011. Medicaid, one of the largest insurers of children, bears almost half this cost (48.4%). 

Looking at nearly two million Express Scripts Medicaid pediatric patients under age 19, overall, just 1.8% of children use a mental health medication. However, when looking at prevalence rates by age group, we see a steady increase in use among older children. Boys show higher prevalence rates than girls up until age 16, when girls overtake them in prevalence by 1.4%.

Mental Health Medication Prevalence by Age Group 

Leading Driver of Overall Cost and Utilization

Despite the lower overall prevalence, pediatric patients taking a psychotropic medication comprise 15.8% of the plan’s total drug costs and 7% of the overall out-of-pocket cost for the patient. On average, children taking psychotropic medications have nearly 3.5 times more overall prescription claims than those who are not using these medications, with an average of 20 claims per year. In addition, the average cost of a prescription is 57% higher ($65) compared to children not using a psychotropic medication. Looking at the contribution of psychotropic medications to utilization and cost, when we remove the psychotropic medications themselves, we see that use of prescription medications among these members is still 2.4 times higher, and the prescription costs for these members is 45% higher compared to members not taking psychotropic medications.

Of the psychotropic medications included in the analysis, most patients (75%) used an antidepressant. Also, the percentage of antidepressant users increases and the percentage of antipsychotic users decreases in the older age bands. Girls were more likely to be prescribed antidepressants than boys (84% versus 68.3%), and conversely, boys were more likely to be prescribed antipsychotic medications than girls (46% versus 25.6%).

Psychotropic Medication Use 

ADHD Is a Driver, but Is It the Whole Story?

While infections are the No. 1 comorbidity for both groups of kids (which is to be expected in this young population), 43.2% of kids taking psychotropic medications also take medication for attention disorders.

Children who use an ADHD medication are higher overall medication users and cost more even if they aren’t taking a psychotropic medication. However, children taking a psychotropic medication who are not using an ADHD medication are still using almost 3 times more medications and costing the plan 35% more ($13.26 more per prescription).

Impact of ADHD Medication 

Patient Care and Support

While there are expected added costs and utilization due to the chronic nature of mental health conditions, having a better understanding of these patients can help Medicaid plans offer more effective patient care and support.

Managed Medicaid plans and PBMs can offer clinical care services to help patients better manage chronic conditions, make wise health decisions and have optimal health outcomes.  For example, Express Scripts specialist pharmacists are in a unique position to provide personalized clinical care for the patient, help manage medication side effects, improve medication adherence and identify and close other gaps in care.

Actionable Data, Actionable Insights

Pharmacy data is powerful in terms of what it can tell us about members’ behavior, care quality and costs. Data can also identify opportunities to drive better health decisions. As the country’s largest provider of pharmacy benefits – the health benefit most often used among consumers – Express Scripts is uniquely positioned to leverage our data and offer states and managed Medicaid plans actionable insights.

These actionable insights can help both state and managed Medicaid health plans as they assess and respond to the impact of the Affordable Care Act and associated enrollment growth – whether through normal growth, Medicaid expansion or the “woodwork effect.” To provide better patient care and support, improve health outcomes and help states better control their Medicaid budgets, it’s important to understand how the Medicaid population and individual populations within it – such as the Children's Health Insurance Program (CHIP) – use prescription medications.

* This list follows the Florida requirement of informed consent for specific psychotropic medications. Classes of medications excluded from the Florida law include ADHD medications and anticonvulsants. Chloral hydrate, diazepam, lorazepam, and midazolam are also excluded.

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